A pregnant client with a history of heroin use is admitted to the birthing unit. The client is currently in a treatment program and has been on stable doses of methadone during her pregnancy. She tells the nurse, “I know my baby may go through withdrawal after delivery. What will happen?” The nurse correctly tells her that her baby may: (Select all that apply)
Sleep deeply.
Have a high-pitched cry.
Not feed well.
Have some shaking.
Sweat a lot.
Correct Answer : B,C,D,E
Choice A rationale
Deep sleep is not a characteristic of neonatal abstinence syndrome; rather, infants tend to exhibit irritability and disturbed sleep patterns due to central nervous system hyperirritability caused by opioid withdrawal.
Choice B rationale
A high-pitched cry occurs due to central nervous system overstimulation and hyperirritability, which are hallmark features of neonatal abstinence syndrome and a direct result of opioid withdrawal in neonates.
Choice C rationale
Poor feeding is common in neonatal abstinence syndrome due to uncoordinated suck reflexes and gastrointestinal disturbances, leading to difficulty maintaining adequate nutrition and hydration in affected neonates.
Choice D rationale
Neonates with neonatal abstinence syndrome often exhibit tremors or shaking as a result of central nervous system hyperirritability, which is a hallmark symptom of opioid withdrawal in newborns.
Choice E rationale
Excessive sweating is a manifestation of autonomic nervous system dysregulation caused by opioid withdrawal in neonates, commonly observed in infants with neonatal abstinence syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Visual impairment, including retinopathy of prematurity, results from immature retinal vascularization and oxidative damage caused by prolonged oxygen therapy in premature infants, leading to neovascularization and potential retinal detachment.
Choice B rationale
Sensitivity to touch reflects neurologic immaturity or overstimulation in premature infants but is not directly associated with oxygen therapy. It stems from underdeveloped sensory pathways and an immature central nervous system.
Choice C rationale
Hyperbilirubinemia arises from excessive bilirubin production or impaired hepatic clearance in neonates, unrelated to oxygen therapy. Factors include hemolysis, immature liver enzyme systems, or delayed feeding initiation.
Choice D rationale
Cerebral palsy, a motor disorder due to non-progressive brain injury, can result from perinatal asphyxia or intracranial hemorrhage, but it is not a direct outcome of oxygen therapy in premature infants.
Correct Answer is B
Explanation
Choice A rationale
Surgical intervention is not the initial step for uterine atony as conservative measures, such as fundal massage, are prioritized to encourage uterine contraction and reduce bleeding.
Choice B rationale
Fundal massage stimulates uterine contraction by mechanically compressing the myometrium, which helps to constrict the spiral arteries and reduce hemorrhage caused by uterine atony.
Choice C rationale
Establishing venous access is critical for fluid resuscitation but does not directly address the underlying cause of hemorrhage, which requires mechanical or pharmacological uterine contraction.
Choice D rationale
Catheterizing the bladder can prevent displacement of the uterus but does not directly address uterine atony. An empty bladder supports fundal massage by allowing proper uterine positioning.
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